A Case of Epiphrenic Diverticulum

Clinical Presentation

Mr. S is 77 years old and complains of severe progressive dysphagia and regurgitation of undigested foods which began 4 years ago. The dysphagia occurs with both solids and liquids. Symptoms were mild at onset, but now he regurgitates at every other meal. He also reports associated chest pain. He has been waking up at night with a choking sensation and has started using 2 pillows to sleep. He denies heartburn or significant weight loss. The differential diagnosis of this patient is:

• 
  Esophageal neoplasm: This diagnosis must be considered in a patient with significant dysphagia. Given the duration of this patient's disease, however, an occult malignancy is unlikely.
  
• 
  Achalasia: Due to worsening dysphagia with both solids and liquids, coupled with regurgitation, this diagnosis must be considered.
  
• 
  Hiatal hernia/paraesophageal hernia: This diagnosis must be considered given the constellation of his symptoms, especially dysphagia and chest pain.
  
• 
  Esophageal dysmotility: The patient's symptoms could be due to nutcracker esophagus or diffuse esophageal spasms.
  
• 
  Esophageal diverticulum: A history of regurgitation of undigested food may be due to a diverticulum, which may be located proximally in the form of a Zenker diverticulum or more distally as an epiphrenic diverticulum; it can also appear in the mid-esophagus as a traction diverticulum.
  

Question 1: Which diagnostic study is least likely to be helpful as part of the initial work-up?
A. Esophageal manometry
B. Upper gastrointestinal (GI) series
C. 24-hour pH study
D. Esophagogastroduodenoscopy (EGD)


View the correct answer

Answer: C. 24-hour pH study.




Please click on "next page" for further discussion.